Module 1 - Thinking About Human Sexuality
1.1 Human Sexuality
The early pioneers in the field of human sexuality were mainly physicians whose conclusions
were based on studies of patients. Unfortunately, these studies were used to generalize about
the sexuality of healthy people. More recently, many disciplines and fields have contributed to
the store of information (and sometimes misinformation) on human sexuality.
The study of human sexuality has a short but intriguing history. A description of its origins,
establishment, and revival is offered in your textbook. In its present-day form, it is comprised of
three components: sex research, sex education, and sex therapy. The practitioners are linked
through journals and national and international meetings.
Spousal Violence
Most of us know about the lack of freedom for women in Afghanistan. Despite countries fighting
for human rights, a law was passed in March 2009 to restrict women's freedoms even further. It
was up for a judicial review in April 2009, said Afghan President Hamid Karzai (Vogt, 2009).
According to Fatima Hussein, who marched to oppose the law, "this law legalizes marital rape,
whenever a man wants sex, we cannot refuse, it means a woman is a kind of property, to be
used by the man anyway that he wants" (UPI, Wednesday, April 15, 2009.)
Mohammad Mohseni, a top Shiite cleric tried to explain why he felt this was a reasonable law.
He said, “It is not possible for all women to pay the same amount of money as men... For all
these expenses, can’t we at least give the right to a husband to demand sex from his wife after
four nights?” (Faiez & Vogt, 2009).
The following are some of the provisions being protested around the world:
1. It is illegal for a woman to resist her husband's sexual advances.
2. A woman needs her husband's permission to work outside the home or go to school.
3. It is illegal for a woman to refuse to "make herself up" or "dress up" if that is what her
husband wants.
In Canada, sexual assault against one’s spouse only became a criminal offence in 1983. In
1993, the UN released the Declaration on the Elimination of Violence Against Women,
establishing marital rape as a human rights violation. Some countries have not been successful
in implementing measures to protect women from marital violence.
Safe Sex
Another worldwide concern is the AIDS epidemic in Africa. In March, 2009, the Pope visited
Africa and suggested abstinence to deal with the problem, but not condoms. There was
worldwide outrage, but it had been said by the head of the Catholic church. The feeling of many
is that people probably won't give up on sex, but they may well give up on safe sex because of
his statement.
Politics in North America
Moving closer to home, we'll look at the United States. The religious right influenced some of
Bush's policies. However, those policies also carried over to outside the U.S.
The following are some of the effects:
1. The highest rate of teen pregnancies in the developed world, p. 287.
2. Banned stem cell research.
3. Restricted "morning after pill" to 18 years and older without a prescription.
4. In 2000, the U.S. withdrew financial aid to international groups that had anything to do
with abortion. This greatly affected women's lives abroad (read this article in The Star to
learn more - Dark alley all too real for many women).
Your textbook stops at the election of President Obama on p.14. The following are changes he
made right after being elected:
1. Lifted the ban on funding by the U.S. to agencies around the world who perform
abortions or give the option to women.
2. Allowed and funded stem cell research.
3. Lowered the age to 17 years for obtaining the "morning after pill."
Fortunately for us, Canadian politicians have largely maintained a separation between religion
and state. However, that is not to say politicians have not been elected with the intention of
changing some laws, particularly concerning abortion. For most of 2015, we had the
Conservative party in power, which came about as a blending of the "Reform party" and the
"Progressive Conservatives." The Reform party had a large number of members from the
religious right who were determined to make changes. Fortunately, we have the Canadian
Charter of Rights and Freedoms which helps maintain individual rights over religious values.
However, be aware anything can be lost with enough votes!
2.1 Female Reproductive Anatomy
The female organs of reproduction include the following: (a) the ovaries, which produce ova; (b)
the fallopian tubes, which transport the ova to the uterus; (c) the vagina; and (d) external organs
that constitute the vulva. The mammary glands, or breasts, are also considered part of the
reproductive system though they are not located in the pelvic area.
You will need to study all the diagrams in the textbook, as you are required to know the structure
and the anatomy. Note in Figure 3.6 in the textbook: the fallopian tube has three sections: the
infundibulum (outer third), the ampulla (middle third), and the isthmus (inner next to the uterus).
Because the ova must be fertilized within a day or two after ovulation, fertilization usually occurs
in the infundibulum area. All terms are considered important in this area, with special note being
given to some under the "key terms"section at the end of the module.
We need to keep an open mind about a long-held assumption expressed in your textbook, on
page 74, that women are born with a finite number of ova. Recent research, reported in the
Toronto Star, April 2009, suggests that stem cells (which create new cells) have been found in
the ovaries of mice. The question is, "is this true of women?" Derek van der Kooy, professor of
molecular genetics at the University of Toronto stated that "Forty years ago, we thought only
stem cells in adults were in blood, now we know about eye, brain, and skin stem cells. Adult
sperm have stem cells so why not adult ovaries?" (Toronto Star, page Living 1, Wednesday,
April 15, 2009).
2.2 Hormones
Hormones are such potent chemical substances that the small amounts the endocrine glands
release must be carefully self-regulated by the body. The monitoring of hormone levels in the
body is achieved through feedback systems. A feedback system may be either negative or
positive. Most of the feedback systems of the body are negative feedback mechanisms. Refer to
Figure 2.1 below for an example of negative feedback. In a negative feedback system, a low
serum level of a particular hormone (i.e., Part B) will cause a sequence of events resulting in an
increased release of that same hormone or vice versa, whereas positive feedback occurs when
the ultimate effects of the system cause the original stimulus to increase in magnitude. For
example, if hormone A were to decrease, it would trigger events to decrease it further or vice
versa.
Negative feedback mechanisms function to control hormone levels in sexual and reproductive
functions. A very simple illustration of a feedback system is the functioning of a household
thermostat. Refer to Figure 2.1 below. The thermostat in the house acts in a similar manner to
the hypothalamus in the body. The thermostat responds to different levels of temperature in the
room, as does the hypothalamus to different hormone levels in the blood. The sensing device
connects the thermostat to the furnace and signals it to increase or decrease fuel needs. This in
turn causes the temperature to change, which once again affects the thermostat or, in the body,
the level of hormones.
With negative feedback, it is a general rule that if a factor becomes excessive or inadequate, a
system kicks in, consisting of a series of changes that return the factor toward a certain mean
value, thus maintaining homeostasis. Essentially, all control systems of the body operate on
negative feedback. Positive feedback, or vicious circle as it is sometimes called, often leads to
instability and, in some severe cases, death. Positive feedback is useful during labour and
childbirth, however, as certain hormones increase and cause increased uterine contractions to
help deliver the baby.
Module 2 - Female Anatomy, Physiology, and Sexual Health
2.3 Female Reproductive Hormones
Your textbook describes 4 phases of the menstrual cycle (pp. 80-82). However, we will use
different terms to discuss the phases in regards to where the changes take place (i.e. ovary or
uterus). If you consult Figure 2.5 in the "Uterine Lining" section of this module, it should help to
clarify the terms used. The terms used to describe each phase refers to what is occurring (e.g.
proliferative phase—increase in uterine lining).
The following discussion flows from the top to the bottom of the charts in the figures in the
"Uterine Lining" section of this module —Figures 2.5, 2.6 and 2.7 are provided because most
books discuss only a 28-day cycle, a cycle which has given rise to many myths. One such myth
is that ovulation occurs in the middle of a cycle, which is true only in the case of a 28-day cycle.
However, your text does briefly mention this is not always the case on page 79. Figures 2.5, 2.6,
and 2.7 represent only three of many different lengths of menstrual cycles that are possible.
We are using Day 1 as the start of menses in the charts as that is how most people describe the
menstrual cycle, but biologically (as stated on p. 79 in the text) menses is the end of the cycle.
Hypothalamus and Anterior Pituitary Hormones
The neurohormone, Gonadotropin-releasing hormone, produced in the hypothalamus, travels to
the anterior pituitary via the portal circulation. It stimulates the anterior pituitary gland to secrete
two hormones referred to as gonadotropins, FSH, and LH. The blood levels of each vary with
rhythmic regularity and are controlled by a negative and positive feedback mechanism. The
FSH plays a dominant role in ovarian follicular growth by causing the granulosa cells in the
follicle to grow and produce estrogen. LH also stimulates androgen production in the follicles'
theca cells, helping to increase the levels of estrogen. LH is also responsible for ovulation, the
final maturation of the oocyte and conversion of the estrogen-secreting granulosa cells in the
follicle to the progesterone-secreting cells. See Figure 2.2 below.
Ovarian Changes
Approximately once a month, on about the first day of menstruation, several primitive graafian
follicles and their enclosed ova begin to grow and develop. See Figure 2.3 below.
The follicles start to secrete estrogen in increasing amounts as they grow. The estrogen acts on
the hypothalamus and the anterior pituitary, and, by means of negative feedback, it inhibits the
production of FSH and LH. Usually only one follicle matures and migrates to the surface of the
ovary. The graafian follicle does not usually ovulate until it has reached the proper size and level
of maturation. Higher levels of estrogen (200 to 300 picograms/ml are present for 2 to 3 days)
have a positive feedback effect on the secretion of FSH and LH resulting in a surge of both FSH
and LH. The surface of the follicle degenerates about 1½ to 2 days (32 to 44) hours after the
onset of the LH surge resulting in ovulation. Kits used to predict ovulation measure this
increasing level in LH. A hormone present in the follicular fluid, oocyte maturation inhibitor,
prevents final maturation of the oocyte until ovulation occurs. This suppression ends just hours
after the LH surge, just prior to ovulation. Ovulation usually occurs 14 days before (plus or
minus one or two days) the next menstrual period begins.
After ovulation, cells of the ruptured follicle enlarge and, due to the appearance of lipoid
substances, become transformed into a yellow-coloured body referred to as the corpus luteum.
It secretes both progesterone and estrogen in increasing amounts. However, the luteal phase is
progesterone dominated as opposed to the estrogen-dominated follicular phase. The peak in
progesterone levels is reached about one week after the LH surge. If implantation does not
occur, the high level of progesterone causes the hypothalamus to signal the pituitary to stop
producing LH and FSH which causes them to decline and the corpus luteum to decompose.
After its decomposition, progesterone and estrogen levels fall to a minimal level. Withdrawal of
these hormones causes the endometrium to shrink, blood flow decreases, and vasodilation
followed by vasconstriction of the arterioles occurs. Ischemia followed by hemorrhage and
tissue disorganization results in a menstrual flow.
If fertilization does occur, the menstrual cycle is modified. The corpus luteum does not
disappear but continues to secrete progesterone and estrogen into the early months of the
pregnancy. If it is removed by any means during the early months, a spontaneous abortion will
result.
Female Hormones
As blood estrogen levels increase in the preovulatory phase, they produce changes in the
uterus. Endometrial cells grow and proliferate, producing a thickening of the endometrium and
glands and an increase in the water content of the endometrium.
In the postovulatory or secretory phase, the blood level of progesterone increases, producing
uterine changes that are favourable for pregnancy. Secretions from glands prepare the
endometrium for implantation of a fertilized ovum. The high levels of progesterone and estrogen
act on the hypothalamus to suppress GnRH and hence LH is released (Refer to the negative
feedback system shown in Part A of Figure 2.1 in the previous section). Figure 2.4 below
compares the secretion of hormones during an average 28-day cycle. Pay particular attention to
the quantities reported to the left of the graphs; they are not all consistent units, but they do
reflect the rise and fall of hormone levels relative to ovulation.
2.4 Gametogenesis
The reproductive system has as one of its basic functions the production of germ cells. The
process, called gametogenesis, takes place in males in the seminiferous tubules and is covered
in Module 3. In females, oogenesis takes place in the ovary.
You should be completely familiar with the two types of cell division involved in gametogenesis.
Mitosis is the process of cell division resulting in daughter cells whose nuclei are exact
duplicates of the original nucleus. This process is depicted in Figure 2
Meiosis is the process unique to germ cell production. In this type of cell division, the daughter
cells have half as many chromosomes as the original cell. This process is depicted in Figure 2.9
below. Meiotic cell division is necessary so that when fertilization occurs, the normal number of
chromosomes is recreated rather than doubled.
Oogenesis
At about 5 months in embryonic development, mitosis of the primordial germ cells produces
diploid oogonia. The ovaries contain six to seven million oogonia which stop multiplying and
never start again. At about nine months gestation, meiosis starts, producing the primary oocyte.
It is still diploid because it stays at the prophase I stage until puberty. The number of primary
oocytes decreases throughout a woman’s life, leaving about three to four hundred thousand by
the time puberty begins. Each primary oocyte is contained in a tiny, primordial follicle (Figure
2.3). These follicles consist of a single layer of granulosa cells. At puberty FSH causes these
primary follicles to enlarge and produce numerous layers of granulosa cells. Some will get larger
and produce vesicles (fluid filled cavities). They are then referred to as secondary, or
developing, follicles. One of these will continue to grow and form an atrum (single fluid filled
cavity) and be transformed into the graafian follicle. As this is happening, the first division is
completed and the secondary oocyte is formed. During the formation of the secondary oocyte,
uneven cytokinesis (division of cell material into each cell) leaves two daughter cells, the
secondary oocyte, and a small polar body (first polar body), both being haploid cells. The
second meiotic division begins but stops at the metaphase II stage. The secondary oocyte or
ovum is still within the graafian follicle in the ovary. Under proper hormonal influence (FSH, LH,
and estrogen), ovulation occurs and the secondary oocyte (ovum) is released. If not fertilized, it
disintegrates within a day or two. If a sperm enters the cytoplasm, the second meiotic division is
complete, forming two unequal size cells. Once this division is complete fertilization can take
place: the haploid nucleus of the ovum and sperm join to produce a zygote. Figure 2.10 below is
a schematic diagram of the process of oogenesis.
2.5 Female Menopause
During menopause some women experience symptoms that interfere with their sexual
functioning. The female hormone changes are covered in detail on pages 83-84 of your
textbook.
Long-term estrogen deficiency has been linked to an increase in osteoporosis (Delmas et al.,
1997). In January, 1980, according to Dr. Marla Shapiro, who is a Toronto menopause specialist,
the North American Menopause Society consumer education chair, and a University of Toronto
associate professor, no data exists to prove or disprove that the new bioidentical hormones
being used by some women as an alternative to synthetic hormones (HRT) are safe (Toronto
Star, 10 January 2008). Some professionals dispute the term “bioidentical hormone” as not
being a scientific term. The chemical composition of a hormone of the same name is the same
no matter where it comes from.
Some women experience atrophic vaginitis (thinning of the vaginal lining) which results in
increasingly painful intercourse. Since few are using HRT, it is reassuring to know there is a cure
for this symptom. According to Dr. W. Gifford Jones (pen name of Toronto physician Ken
Walker) in February 2008, “daily (or nightly) insertion of the estrogen tablet “Vagifem” for 14
days is the regimen that treats symptoms of atrophic vaginitis and restores the vaginal lining to
its normal thickness. Then to prevent a recurrence, it can be used once or twice a week” (p. C9).
2.6 Osteoporosis
Osteoporosis is increased brittleness and porosity of bones. They break more easily and
women develop a "dowager's hump." Often it results in an increase in serious fractures
especially of the hip. This is becoming a major problem for Canada's health care system as the
population ages. A large study, the Canadian Multicentre Osteoporosis Study (CAMOS), was
carried out because many of our estimates have been based on data from the United States
and other countries. The final phase of the study was completed in 2013. According to Dr.
Gifford Jones in the Health Digest, "The Osteoporosis Society of Canada estimates that one in
four women and one in eight men over the age of 50 have the disease," one that "robs people of
their mobility and independence while causing much pain and disability" (p. 32). Most of the
research has focused only on females over 50 years of age.
Tests that can be done to assess risk of fractures are the bone mineral density (BMD) and
ultrasound. Those at increased risk are those with a family history, European or Asian heritage,
small-boned people, those taking medications (for asthma, arthritis, thyroid), early menopause,
irregular menstrual cycles, too little calcium in one's diet, smoking, and excessive alcohol and
caffeine use.
In addition to the treatments mentioned under menopause here and in the text, there is also a
group of drugs known as bisphosphonates which help reduce bone loss. One of these is
Fosamax (alendronate).
Careful attention to lifestyle and diet can also help, but this needs to start at a young age.
Dysmenorrhea
Primary dysmenorrhea, one of the most common problems of menstruation, can be treated
more effectively today by using antiprostaglandins which are obtained by prescription from a
family physician. There is no need for women to be in bed for 2 or 3 days with severe cramps.
Such cramping during menstruation is usually due to an excess of prostaglandins being
secreted from the walls of the uterus.
Toxic Shock Syndrome
Toxic Shock Syndrome (TSS) is a disease caused by staphylococcus aureus.
PMS
New information is available in your text (p. 85) regarding the treatment of PMS. Many studies
have been done and are continuing to be conducted, so more information will become available
in the future.
2.8 Cancer of Reproductive Organs and Breast
Cancer of the Breast
This is the most common form of cancer in women. The first symptom of breast cancer is a
small lump. As you can see in the statistics on pp. 77-79, early detection and treatment reduce
the risk of mortality. Your textbook admits to the controversy around detection. However, a good
philosophy is to do the utmost to keep yourself safe; therefore, we are including the
recommendations from the previous text (Rathus et al., 2007), as the best course to follow.
"The Canadian Cancer Society (2002) recommends the following screening practices to detect
breast cancer:
1. Mammography every 2 years for women between the ages of 50 and 69 (in Ontario).
2. Clinical breast examination by a trained health professional at least every 2 years for all
women.
3. Regular breast self-examination monthly. Women should report any changes to their
doctor (Rathus et al., p. 69, 2007).
Nancy Devine in the Toronto Star (Thursday, September 27, 2001) discussed some
controversial recommendations that were made regarding BSE. “The CMA Journal published
results of a study by the Canadian Task Force on Preventive Health Care, which reviewed other
studies involving thousands of women in the U.K., the U.S., China, Russia, and Canada. The
task force determined that self-exams don’t really impact the survivability rates among women
who routinely perform them.” However, Karen DeKoning, president of the Canadian Breast
Cancer Network, argues “BSE is still a useful tool in helping women understand their bodies.”
Dr. Fei-Fei Liu, radiation oncologist at Princess Margaret Hospital and a senior scientist with the
Ontario Cancer Institute, also believes ‘BSE is still valuable.’ She was concerned that women
would no longer do BSE and that even though it is not an effective screening tool, in that it won’t
detect a tumour until it can be felt, it is better than the old days when we might see very
advanced breast cancers. Until there is a magic blood test to detect early breast tumours, she
thinks it is reasonable to show women how to properly do BSE. Valerie Hepburn, chairperson of
the Ontario Chapter of the Canadian Breast Cancer Foundation, says “BSE is still valuable, and
that young women between the ages of 16 and 19 should be taught how to do monthly checks.
That way, they know when things are different.”
Your text discusses prevention and treatment of breast cancer but it says nothing about what
happens if you are not cured. This is a fault in most of the literature at this time.
When the cancer returns and it has spread to other sites, it is referred to as metastatic disease.
Treatments have changed greatly over the past five years and continue to do so. Many patients
and people working in the field, share Nancy Devine’s report of patients’ comments in the
Toronto Star Thursday, September 27, 2001 that “they can foresee a time when metastatic
breast cancer might be a chronic disease, as opposed to a life-threatening one.” When
someone is diagnosed they go through a lot of stages but most are confident they will recover.
However, “those with a metastatic diagnosis have different questions and need different
information.” They are filled with terror and hopefully get some good support in order to put
themselves into a “combat position” in order to deal with the mental and physical effects of the
treatments they will have to undergo for the rest of the time they have left. Each year, this time
is being extended by treatments and each individual reacts differently to their treatments.
According to Dr. Jennifer Keck a Laurentian University professor who died of metastatic breast
cancer, the video “How Can We Love You” deals with “the difficult issues related to living with a
life-threatening illness, the meaning of life and hope, as well as death and dying. But it is first
and foremost about relationships and caring for the people we love.”
Cancer of the Cervix
This is the second most common cancer in women. A Papanicolaou (PAP) smear should be
done every 3 years beginning at 20 years of age or once sexual activity starts. According to Dr.
Bruce Barron in The Sudbury Star, “The frequency with which a woman should have Pap
smears depends on her age, sexual history, and other factors. Some women need to have them
every six months, while others may require a Pap smear every three years or even less
frequently” (p. B2). Cervical Intraepithelial Neoplasia (CIN) describes cancerous or
precancerous changes of cervical epithelial cells. It is found in the transition zone of the cervix
where the vaginal squamous epithelial cells and endocervical columnar cells meet. This zone
extends into the vagina during and just after puberty. As a woman ages, it retreats into the
endocervical canal. A Pap smear specimen includes an endocervical swab from the
transformation zone. Pap smear results are graded on a scale from I-V:
Class I Pap no abnormalities
Class II Pap benign atypical and CIN 1
(mild) or 2 (moderate) dysplasia
Class III Pap CIN 3 (severe) dysplasia or
worse
Classes IV and V Pap Invasive carcinoma
Any abnormal changes in these cells are monitored by the doctor and more frequent tests or
treatments done as necessary. In 70% of cases a colposcopy is done if the cells on the original
PAP smear are abnormal (within Class II Class V). This test is done by a specialist in a hospital
with a special instrument (colposcope) that examines more closely the cells of the entire
transformation zone. If treatment is necessary, it usually consists simply of removal of the
dysplastic tissue by colposcopic biopsy or cryosurgery. Laser vaporization can also be
performed. If the transformation zone is not entirely visible, the doctor may perform endocervical
curettage.
Follow up with repeat Pap smears is important, as is the need always to follow up on any
appointments for Pap smears; these steps can prevent any advancement of cervical cancer.
Changes in Pap smears are currently appearing at earlier ages, such as in the early twenties.
Module 3 - Male Anatomy, Physiology, and Sexual Health
3.1 Male Reproductive Anatomy
The organs of the male reproductive system include: a) the testes or male gonads, which
produce sperm; b) a number of ducts that either store or transport sperm to the exterior; c)
accessory glands that add secretions comprising the semen; and d) several supporting
structures, including the penis.
A detailed illustration of the penis can be seen in Figure 3.1 below.
Autonomic Nervous System
When referring to the automatic reflexes (unlearned) of the autonomic nervous system, it is
better to use the following terms: stimulus directly from the brain is referred to as psychogenic
stimuli and stimulus received as a result of touch is referred to as reflexogenic stimuli.
3.2 Male Reproductive Hormones
The co-ordination of the male physiological events is governed by the hypothalamus, the
pituitary gland, and the testes. If testosterone levels fall, a sequence of events occurs to keep it
at a more or less constant level. Figure 3.2 below shows the major male reproductive hormones.
FSH RH follicle stimulating hormone releasing hormone and LH RH lutenizing hormone
releasing hormone are secreted by the hypothalamus. They stimulate the anterior pituitary to
secrete the hormone testosterone. The FSH stimulates the seminiferous tubules in the testes to
produce sperm cells. LH and testosterone are then responsible for promoting the maturation of
the developing sperm cells spermatogenesis). It has been shown that the male testosterone
plays an important role in initiating and sustaining human sexual interest, often referred to as
libido.
3.3 Spermatogenesis
The following commentary, including Figure 3.3 below, provides a more detailed explanation of
the process of spermatogenesis than that in your textbook (p. 91). This process occurs in the
seminiferous tubules of the testes. It begins when the primordial germ cells migrate from the
yolk sac during early embryonic development to the testes to become “stem cells” called
spermatogonia. Only about one to two thousand stem cells migrate; therefore, in order to
produce millions of sperm throughout adult life, the spermatogonia duplicate themselves by
mitotic division and only one of the two goes on to meiotic division. This allows spermatogenesis
to go on forever. In the mitosis phase, a diploid parent spermatogonia near the outer wall of the
seminiferous tubules undergoes mitotic division. This creates two diploid daughter cells, one of
which remains close to the wall of the seminiferous tubules to continue undergoing mitosis and
creating more daughter cells, while the other continues on to the next stage. At puberty, when
testosterone secretions rise, completion of meiotic division and early maturation of spermatids
occur.
Next, the diploid daughter cell, called a primary spermatocyte, undergoes meiosis, a process in
which it is reduced to two haploid daughter cells, called secondary spermatocytes, but the
chromosomes are still in duplicate form (have 2 chromatids). These two secondary
spermatocytes undergo a second meiosis, producing four haploid spermatids, which each
contain single chromosomes (have 1 chromatid). At the end of the second meiotic division, the
cytoplasm of the cells is interconnected. During the process of spermiogenesis, the Sertoli cells
absorb the cytoplasm leaving the spermatozoa. During this process, the sperm gradually get
pushed to the centre of the seminiferous tubules, and through to the epididymis where they
actually become motile. This short trip takes 20 days. In a human male, this formation process
takes about 65‑75 days.
3.4 Male Climacteric (Andropause)
Gail Sheehy's book Understanding Men's Passages has an excellent section on these changes
and the various research and treatments being used. She has developed the following
categories to describe the sexual stages in a healthy man's life:
As we see in the text, men's testosterone levels decrease with age. The bioavailable
testosterone (bio T), the active fraction of testosterone, is the important testosterone—not the
inactive non bioavailable testosterone. When levels are assessed, it is important to check for the
bio T levels. Some symptoms that may be noticed are a change in personality from positive and
energetic to negative, pessimistic, and less productive, osteoporosis, sleep disturbances,
irritability, and nocturnal sweating. Not just testosterone, but human growth hormone and DHEA
(Dehydroepiandrosterone) decline, and DHEA levels should also be checked. The biggest
problem seems to be that men tend to avoid discussing these problems, and often physicians
do not introduce an opportunity to do so. Hopefully, with the advent of "Viagra," this is changing
a bit. According to urologists in Sheehy's book, "It is much easier to prevent male menopausal
impotence than to correct it. The early phase of stuttering potency can become psychologically
toxic if ignored. The longer a man waits before he seeks treatment or makes healthy changes in
his lifestyle the harder it is to help him regain his sexual vitality. And once a man develops the
habit of impotence, it is extremely hard to break" (p. 192).
Testosterone capsules can restore testosterone levels and help diminish some of the symptoms.
However, there are no magic bullets, despite what we hear from the general media today. The
following, along with aging, can affect potency: smoking (damages the tiny blood vessels in the
penis), heart disease (medications), high cholesterol (high HDL levels increase the chance of
impotence), alcohol (kills nerves inside penis), cocaine (most detrimental drug), diabetes, stress,
depression, and anger.
Several doctors quoted by Sheehy say that "Prevention—through exercise, good nutrition and
other healthy habits, and cultivating intimacy with a mate and more friends—is the key to
minimizing the adverse effects of aging and stress on male potency" (p. 198).
A Canadian Andropause Society is now in existence.
According to Dr. Morales, director of the Center for Applied Urological Research at Queen's
University in Kingston (Kaye, 2007), "large long-term studies on the efficacy and safety of
testosterone replacement therapy have not been done. "Testosterone therapy may be a trial and
error business. Some men improve on it and some have no change."
3.5 Gynecomastia
This also occurs with aging in some males. A decrease in the testosterone levels creates an
increase in the ratio of female to male hormones. This decrease can also be caused by the use
of some heart and stomach medications, marijuana, and anabolic steroids. In rare cases, it
could be due to cancer. Those with breast cancer usually do not experience any discomfort,
whereas those with benign (not cancerous) gynecomastia often experience pain or at least
some tenderness. Often the situation will resolve itself; if not, drugs causing the problem have to
be discontinued, or testosterone prescribed. If none of these produce satisfactory results,
surgery can be considered.
3.6 Cancer of the Reproductive Organs
Cancer of the Prostate
Cancer of the prostate is the most common cancer in older males. According to a “Wellness
Report” put out by Manulife Financial, “It is one of the greatest health risks facing Canadian
men. After lung cancer, it is the second deadliest cancer in males. It killed approximately 4,300
men in Canada in 1998.” The Cancer Society “estimates 17,800 new cases will be diagnosed in
2001, and 4,300 will die from the disease.”
Prostate cancer behaves differently in different men. In some it stays in the one site and has no
effect, in others it spreads rapidly. The problem is that many of the early symptoms mentioned
on page 95 are the same as those for non-cancerous prostate enlargement which affects more
than half the men over 50. One symptom not mentioned in your text is painful ejaculation. Later
symptoms are listed on pages 95-96. The incidence of prostate cancer has doubled since 1969.
Approximately 1 in 9 Canadian men will develop it and 1 in 27 will die from it.
The best method of early detection is by an annual physical check-up which should usually be
done starting at 50 years of age if risk factors exist. A prostate specific antigen blood test, digital
rectal exam and a transrectal ultrasound should be done. If any of these tests are positive, a
rectal probe and a biopsy may be done.
According to Prithi Yelaja in the Toronto Star October, 2001, “Doctors at Toronto’s Princess
Margaret Hospital have pioneered a new treatment that offers hope of a cure for prostate cancer
patients whom traditional radiation therapy has failed. Needles are inserted into the tumour. The
needles are attached with small antennae that emit microwaves into the prostate, heating it up
to 55o C for 15 minutes. This kills all the cells in the prostate. The procedure is performed under
general anaesthetic and entails an overnight stay in hospital.” Dr. Sherar, head of radiation
physics at Princess Margaret, said “Although these early findings show the procedure has
potential, further study in large groups for longer periods of time is needed to determine the
durability of this therapy.”
Given the side effects of treatment for prostate cancer some recent study results may help make
informed choices. In February 2008, Grace Lu-Yao of Robert Wood Johnson Medical School in
New Jersey released new information. There is no sure way to tell which tumours will grow
slowly or fast. “The new study looked at the natural course of the disease in of the disease in
men who chose that option [to delay or skip treatment]. It is the first involving so many older
men—half were over 75—and so many whose tumours were found through PSA tests” (Guelph
Mercury, Feb. 14, 2008). Only 10% in the study who chose to delay or skip treatment had died
of prostate cancer a decade later. The vast majority were alive without significantly worsening
symptoms or had died of other causes. However, if people are younger or have more advanced
disease she would not recommend delaying treatment. Dr. Howard Sandler, a radiation and
prostate specialist at University of Michigan, agreed, but cautioned, “there are exceptions to
every rule; and some very active, healthy older men may do better having treatment right away,
along with older men who have higher-grade tumours.”
Cancer of the Testes
Cancer of the testes is most common in males 15 to 40 years of age. Although it affects small
numbers of males, it is worthwhile practicing testicular self-examination, as shown on page 95.
Early detection can prevent spreading of the cancer.
According to San Grewal in the Toronto Star, August, 2000, “Testicular cancer affects 5.3 of
every 100,000 Canadian men and is the most common form of cancer in men between 20 and
35. The Canadian Cancer Society projected 820 new cases in 2000. The rate has increased
every year since 1988.” “The mortality rate is low, as is the risk of sexual dysfunction or infertility
after having a testicle removed.” According to Dr. P. Warde of the Princess Margaret Hospital
“even if an early detection is not made there is still a more than 80% success rate with
treatment. But if chemotherapy or radiation has to be used after the cancer spreads there is an
increased chance that fertility could be affected.” It is important for young men to do monthly
exams, so that they know what their testes feel like normally. If a small lump is detected they
should contact their doctor. Another symptom might be a dull pain in the groin or lower
abdomen. If testicular cancer is not detected early it can cause swelling of the breasts, small
cherry-stone sized lumps in the neck near the lymph nodes in the hollow of the collar bone.
Module 4 - Sexual Response, Arousal, Techniques, and
Behaviour Patterns
4.1 Aphrodisiacs
Aphrodisiacs are substances that supposedly increase sexual desire, performance and
frequency. Contrary to reports, there are no true aphrodisiacs and some of the substances that
are popularly thought to act as aphrodisiacs can be dangerous to one's health. Extensive use of
recreational drugs usually results in poorer sexual functioning.
4.2 Cerebral Sex
When referring to sexual response and the brain, especially with spinal cord injuries remember
the terms used in the last module for the autonomic nervous system (ANS)—pyschogenic and
reflexogenic stimuli.
4.3 Sexual Response
Before the 1960s, relatively little was known about the way the body responds during sexual
arousal. What we know now about responses to sexual stimulation stems from the work of
Masters and Johnson. They provided the first factual, scientific data on what actually happens in
terms of anatomical and physiological changes during sexual activity.
Module 5 - Development of Sexuality
5.1 Gender and Terminology
The following definitions for various aspects of gender help clarify the terms used in the
textbook:
Gender identity refers to our inner sense (psychological sense) of being male or female. Social
learning can affect how we see ourselves with respect to being male or female. However, our
gender identity is probably influenced by a complex interaction between biological and
psychological factors.
Gender roles are social and cultural expectations for male and female behavior, which may vary
from one society to another.
-Assigned sex is determined by our external genitals (biological make up). Gender identity and
gender roles may be related to our sexual identity. However, as you will see in Chapter 5, this is
not always the case. When sexual identity does not agree with gender identity, the individual
experiences gender dysphoria which often results in the person being referred to as
transgender.
Sexual orientation refers to the people to whom we prefer to relate intimately or sexually. This,
as you will see in Chapters 5 and 9, does not rely on any of the previous three.
NOTE: Your textbook uses the terms "homosexual" and "homosexuality" though many gay and
lesbian people object to these terms. See page 236 for a discussion of the controversial use of
these terms. This course will not use these terms. The link below provides an introduction to
appropriate vocabulary as well as terms to avoid.
5.2 Development of the Embryonic Reproductive System
This topic is presented here in more detail than in your text. It is important to understand the
significance of the Y chromosome and the androgenic hormones in the sex differentiation
processes illustrated in Figures 5.1 and 5.2 in your text. The undifferentiated genital system of
both sexes appears during the 4th to 6th week of intrauterine life. In the undifferentiated stage,
the embryo has two sets of ducts: Müllerian (potential female) and Wolffian (potential male). The
Y chromosome initiates the organizing of a substance called the H‑Y antigen. This causes the
undifferentiated gonads in the male to become the testes. The testis-determining factor (TDF)
found on the Y chromosome is a male’s biological “master switch,” causing the seminiferous
tubules to start forming. The testes are recognizable by 7 weeks. Testosterone produced by the
embryonic testes is necessary to promote the maturation of the seminiferous tubules.
Testosterone from the testes causes further differentiation in the Wolffian system and the
production of Müllerian-inhibiting hormone by the testes causes the Müllerian ducts to
degenerate, resulting in male reproductive organs. In the absence of the testicular hormones,
the Wolffian ducts degenerate and the Müllerian ducts develop, resulting in female reproductive
organs. See Figures 5.1 and 5.2 below. The embryonic ovary also produces estrogenic
hormones, but their role in the further development of the ovaries is unclear.
A single gene on the Y chromosome labeled SRY may be the sex-determining gene on the Y
chromosome. Its presence or absence may determine whether ovaries or testes develop.
5.3 Androgen Insensitivity Syndrome
The androgen insensitivity syndrome (AIS) is an example of an intersex condition and is caused
by a recessive gene on the X chromosome. Since females (XX) have two X chromosomes, the
problem is not manifested because of a normal dominant gene on the other X chromosome.
However, they would be carriers and could pass on the gene.
In males (XY) there is no room on the Y chromosome for a normal gene; therefore the recessive
AIS gene on the X chromosome causes the male to display the characteristics of the syndrome.
The male/female (XY) person with AIS develops female external sex organs even though the
gonads (in the abdomen) are producing testosterone. The developing body cannot use the
testosterone because the androgen binding sites do not work. Therefore the male's duct system
"Wolffian" fails to develop into the epididymis, vas deferens, seminal vesicles and ejaculatory
ducts. The male fetus still produces Müllerian inhibiting hormone which prevents the
development of the female Müllerian ducts (uterus and fallopian tubes). However, externally
they have small vaginas and are therefore assumed to be a female. The adrenal glands also
secrete the normal amount of male estrogen, but because it is unopposed by testosterone, they
develop secondary sex characteristics of a female.
They have breasts, hips, little pubic hair but are unable to menstruate or reproduce.
Psychologically these females usually feel entirely feminine.
5.4 Transgender
As mentioned in your textbook, previous editions of the text used the term “transsexualism.”
However, this term is no longer used because it implies that being transgender is a medical
condition (Rathus et al., p. 140). The term transgender (trans) is typically preferred, and refers to
people who identify as a gender that does not reflect their biological sex.
When reading about this area and other areas of non-traditional sexual development, note the
dates of research and theories that are proposed. Much has been learned since the 1960s,
1970s, and 1980s keeping in mind that we still have a lot to learn and many theories are just
that and not conclusive evidence of cause and effect. They do however encourage us to be
more generous in our understanding of people who are non-traditional.
Transgender issues are becoming increasingly visible, due in large part to individuals and
organizations that advocate for the rights and safety of transgender people. Media coverage of
transgender issues has also helped to raise public awareness and to increase support for
transgender people.
In an episode of 20/20 (My Secret Self), Barbara Walters interviewed a number of young
people. They agreed with the findings in the text that “transgender people usually show
cross-gender preferences in play and dress during early childhood” (Rathus et al., p. 140). They
expressed a great sense of gender dysphoria at a very young age.
5.5 The Effect of Gender Roles on Sexual Behaviour
As you can see, gender roles have a great effect on sexual behaviour. We need to understand
that in the past and even today many of the theories were and still are written and proposed by
men much as history and other fields have been biased by only having one perspective. We
need to have a lot more research in these areas. Rathus et al. note that, "Fortunately, more
flexible attitudes are emerging" (p. 152). One of the most important points made twice in
Chapter Five is that "It appears that common perceptions may overemphasize gender
differences. There's usually greater variation within each gender than between the genders
(Muehlenhard, 2000)…" (p. 153). Note on page 254, the stereotypes that exist regarding the
sexual behaviour of gay and lesbian people.
5.6 Discrimination
Many students in previous years have felt that discrimination and abuse of gay individuals was
not a problem today. If you are not a member of this community you may be unaware of the
issues faced by gay people. Current statistics are provided on page 252 on abuse that
homosexual youth are still experiencing today. Problems still exist, and it is serious enough that
groups have formed to "show youth that there is a support system for them and that they are not
alone." David Clark, an activist, supported the "Day of Silence" which is "part of a national
movement across Canada and the U.S., a reminder of the many people, particularly youth, who
feel their voices aren't heard because of their sexuality (Guelph Mercury April 18, 2009, page
A4).
5.7 Adulthood
Adulthood is a dynamic period of continuing change and growth. This period can be divided into
three categories: youth, mid life, and aging. During youth (years 17-22), sexual unfolding is the
chief developmental task. During this period, dating allows young people to become more
comfortable with sexual negotiations, intimacy, commitment, and fidelity.
We do not have a systematic picture of normative changes during middle and late adult years.
However, various studies indicate that frequency of intercourse in marriage varies with age: for
young couples it is 3.25 times a week; for those 25-34 years it is approximately 3 times a week
with a continuous decrease of frequency with age (Harmatz & Norah, 1983, p. 336). Changes in
male and female sexual response alter with increasing age.
Sexuality in the elderly can be adversely affected by a number of factors, including poor health,
chronic diseases, and the side effects of medication. Because our knowledge of sexual
behaviour in the elderly is based on highly limited samples, it may not accurately reflect the
elderly population as a whole. However, we do know that sexuality is not a dimension that
suddenly ends in mid-life; it is, in fact, an important part of life that can continue physically and
be enjoyed indefinitely.
5.8 Sexual Health Education
Sexual health education in schools can be a controversial topic. Your textbook highlights the
importance of sexual health education for not only problem prevention, but also for recognizing
sexual health as a positive aspect of health.
In early 2015, changes to Ontario's sexual health education curriculum resulted in controversy
when some parents felt the new curriculum was too explicit. This was due, in large part, to
misinformation and misunderstanding regarding the changes.